Seven-Year Process Edges Closer to Alignment with National Standards

By Susanne J. Phillips, DNP, RN, APRN-CNP, FNP-BC, FAANP
and Garrett Chan, PhD, RN, APRN-CNP, CNS, FAEN, FPCN, FCNS, FNAP, FAAN

On January 15, 2019, the California Secretary of State and the Office of Administrative Law (OAL) endorsed and approved a major revision to Division 14 of Title 16 of the California Code of Regulations. The amended and added regulatory sections pertain to nurse practitioners (NPs) and include definitions, categories of NPs including title, NP certification, NP education, and requirements for out-of-state NP programs. You can download all OAL documents describing the approval process and amendments to previous regulations.

Background & History

Original approval and adoption of NP regulations in California occurred in July 1979, with subsequent amendments in 1985 and 1986. Although statutes (laws) have been enacted affecting NP practice since that time, regulations pertaining to NP recognition and certification, evaluation of credentials, as well as requirements for NP education programs, have not been updated in over 30 years.

In 2008, the national advanced practice registered nursing (APRN) community jointly approved the Consensus Model for APRN Regulation, providing a national statutory and regulatory model for state adoption pertaining to licensing, accreditation, certification, and education of APRNs. This massive joint effort provided the building blocks for states to develop consistent regulatory language across the nation. This effort gained further momentum with the publication of the Institute of Medicine’s (IOM) Future of Nursing Report in 2010, where states were encouraged to adopt model APRN statutory and regulatory language.

The effort to modernize California’s APRN regulations began in early 2012, when the California Action Coalition (CAC) Workgroup #1 (Scope of Practice) committed to work on this effort as part of its APRN strategic plan. Leadership within the CAC with experience in APRN regulation spearheaded a joint effort between the APRN Coalition, comprised of all professional APRN associations, the American Nurses Association/California, and staff from the Board of Registered Nursing (BRN). Strategic planning was underway by July 2012 and the CAC provided supportive testimony to the BRN’s Nursing Practice Committee on the importance of modernizing APRN regulations in California and requesting their support. By late 2013, the Board of Nursing approved efforts to focus on regulatory changes but limited the work to NP regulations with an understanding that other APRN roles would follow thereafter.

From November 2013 through mid- 2015, the CAC convened stakeholders to discuss amendments and needed additions to existing NP regulations, including providing expert testimony and recommendations to the BRN Nursing Practice Committee on multiple occasions. In September 2015, the BRN Nursing Practice Committee opened public discussion regarding NP regulations, holding hearings over the course of the next five months. After diligent work by BRN staff and members, along with significant input from APRN leadership, the first draft of modified regulations and material added to the rulemaking file was submitted to the OAL in May 2016. The OAL opened the file for public comment in November 2016. In total, the proposed regulatory amendments and additions were modified and went back for public comment five times, with the last comment period closing in mid-October 2018. The Office of Administrative Law finally approved the regulatory package January 15, 2019.

Highlights of Regulatory Content Added and Amended

The following provides highlights of the sections amended or added to Division 14 of Title 16 of the California Code of Regulations:

1480: Definitions (Modified and New) – last amendments – 1985

1. Modification of the following definitions: NP, primary care, and clinically-competent. 
2. Adds the following definitions: acute care, category, advanced health assessment, advanced pathophysiology, advanced pharmacology, nurse practitioner curriculum, graduate core, advanced practice registered nursing core and related definitions, clinical practice experience, direct supervision of students, and national certification (not required to practice in California).

1481: Categories of Nurse Practitioners (Modified)

1. Regulatory changes authorize the BRN to recognize NP specialties in alignment with the consensus model of APRN regulation: family, adult/geriatric primary care, adult/geriatric acute care, pediatric primary care, pediatric acute care, neonatal, women’s health, and psychiatric/mental health. NPs nationally board-certified outside of the currently recognized specialties will be recognized accordingly.
2. NP title: “APRN-CNP.” The NP specialty follows in alignment with national board certification standards, if applicable (I.e.: An adult/gero acute care NP would use the following: Jane Doe, RN, APRN-CNP, ACAGNP-BC or ACNPC-AG).

1482: Requirements for [California BRN] Certification as a Nurse Practitioner (Modified)

1. Certification – valid and active RN license, master’s degree in nursing, master’s degree in a clinical field related to nursing, or graduate degree in nursing and one of the following: 
   1. Completion of a NP program approved by the BRN, or 
   2. National board certification as an NP in a specialty.

1483: Evaluation of Credentials (Modified)

1. Clarification on forms required to apply for licensure to practice in California.

1483.1 Requirements for Nurse Practitioner Education Programs in California (New)

1. All California NP programs are within an accredited academic institution located in California that offers a graduate degree in nursing or graduate-level certificate in nursing (post-graduate certificate programs).
2. NP programs must be accredited by a national organization recognized by the US Department of Education or Council of Higher Education (Nursing: CCNE or CNEA).
3. BRN approval of an NP program is predicated on national accreditation.

1483.2: Requirements for Reporting Nurse Practitioner Education Program Changes (New)

1. Stipulates requirements for academic programs to report changes to an NP program.

1484: Nurse Practitioner Education (highlights only - see regulation for additional and specific language) (Modified and New)

1. Mandates NP curriculum is in alignment with the National Organization of Nurse Practitioner Faculties (NONPF) NP Core competencies content.
2. The program must prepare the NP for national certification in a specialty.
3. Transcripts must document NP role and category of specialty (Family, Women’s’ Health, etc.).
4. Stipulates requirements and responsibilities of the NP program director.
5. Authorizes NPs, CNMs, CNSs, or CRNAs to be faculty as appropriate.
6. Clinical courses must have actively practicing faculty assigned as appropriate.
7. Authorizes the following healthcare providers to precept NP students as appropriate to their clinical training needs:
   1. NP, CNM, CRNA, or CNS
   2. Other California-licensed healthcare professional appropriate to the area of clinical training (ie: DPT, OD, MD/DO, DPM, Psychologist/MFT/LCSW, PA, etc.).
8. Preceptor requirements, functions and evaluation by program/faculty.
9. All NP students hold an active, valid California RN license to participate in clinical experiences.
10. Curriculum must be in alignment with NONPF Core competencies and respective specialty competencies for the categories of NPs being educated. Must include graduate core, APRN core, NP core role competencies and specialty competencies, and California regulations on furnishing and standardized procedures.
11. Must be eligible to sit for national board certification specialty exam upon graduation.
12. NP program must arrange clinical instruction and supervision.

1486: Requirements for Clinical Practice Experience for Nurse Practitioner Students Enrolled in Non-California based Nurse Practitioner Education Programs (New)

1. Non-California-based NP programs requesting clinical placements in California must be approved by the BRN.
2. Clinical preceptors must meet BRN requirements.
3. The program must secure preceptors and ensure experiences meet NONPF core and specialty competencies.
4. The program must ensure experiences meet NONPF core competencies. 
5. Students enrolled in out-of-state programs must have an active, valid California RN license to participate in clinical experiences.
6. The program must include curriculum on standardized procedures regulations, California NP scope of practice, and furnishing statutes.

Implementation

The BRN staff is currently working on implementation of the regulations and will notify licensees when operational measures are developed and ready for implementation. NP programs will be notified of the changes, and BRN Nursing Education Consultants will assist NP programs with compliance of the new regulations.

Summary: Why is this important to me?

Nurse practitioner leaders are working to align California’s statutes and regulations with national standards, and the recent adoption of new and modified regulations support national alignment.

So what does this mean at the end of the day? California’s nurse practitioners are defined in statue as APRNs. However, our titling has not reflected this national standard until this time. Additionally, the BRN has not previously recognized our NP specialty, which is now changed. Regulatory recognition of our NP specialty is important for local, state and national workforce data collection, again in alignment with national standards. Further regulations assist California NP programs in providing nationally recognized curriculum and adherence to clinical preceptorship standards, as well as providing detailed direction for NP program leadership.

Be sure to review mailed and emailed information from the BRN pertaining to the new regulations and contact CANP if you have questions about implementation.

Susanne J. Phillips is an Associate Dean at the UC Irvine Sue & Bill Gross School of Nursing, and is the former CANP Director of Health Policy & Practice. Garrett Chan is the President & CEO of HealthImpact, and an Associate Adjunct Professor at UC San Francisco.